[Safety and effectiveness of esophagojejunostomy through extracorporeal versus intracorporeal methods after laparoscopic total gastrectomy].

Objective: To compare the safety and effectiveness of esophagojejunostomy (EJS) through extracorporeal and intracorporeal methods after laparoscopic total gastrectomy (LTG). Methods: A retrospective cohort study was carried out. Clinicopathological data of 261 gastric cancer patients who underwent LTG, D2 lymphadenectomy, and Roux-en-Y EJS with complete postoperative 6-month follow-up data at the General Surgery Department of Nanfang Hospital from October 2018 to June 2021 were collected. Among these 261 patients, 139 underwent EJS with a circular stapler via mini-laparotomy (extracorporeal group), while 122 underwent intracorporeal EJS (intracorporeal group), including 43 with OrVil(TM) anastomosis (OrVil(TM) subgroup) and 79 with Overlap anastomosis (Overlap subgroup). Compared with the extracorporeal group, the intracorporeal group had higher body mass index, smaller tumor size, earlier T stage and M stage (all P<0.05). Compared with the Overlap subgroup, the Orvil(TM) subgroup had higher proportions of upper gastrointestinal obstruction and esophagus involvement, and more advanced T stage (all P<0.05). No other significant differences in the baseline data were found (all P>0.05). The primary outcome was complications at postoperative 6-month. The secondary outcomes were operative status, intraoperative complication and postoperative recovery. Continuous variables with a skewed distribution are expressed as the median (interquartile range), and were compared using Mann-Whitney U test. Categorical variables are expressed as the number and percentage and were compared with the Pearson chi-square, continuity correction or Fisher's exact test. Results: Compared with the extracorporeal group, the intracorporeal group had smaller incision [5.0 (1.0) cm vs. 8.0 (1.0) cm, Z=-10.931, P=0.001], lower rate of combined organ resection [0.8% (1/122) vs. 7.9% (11/139), χ(2)=7.454, P=0.006] and higher rate of R0 resection [94.3% (115/122) vs. 84.9 (118/139), χ(2)=5.957, P=0.015]. The morbidity of intraoperative complication in the extracorporeal group and intracorporeal group was 2.9% (4/139) and 4.1% (5/122), respectively (χ(2)=0.040, P=0.842). In terms of postoperative recovery, the extracorporeal group had shorter time to liquid diet [(5.1±2.4) days vs. (5.9±3.6) days, t=-2.268, P=0.024] and soft diet [(7.3±3.7) days vs. (8.8±6.5) days, t=-2.227, P=0.027], and shorter postoperative hospital stay [(10.5±5.1) days vs. (12.2±7.7) days, t=-2.108, P=0.036]. The morbidity of postoperative complication within 6 months in the extracorporeal group and intracorporeal group was 25.9% (36/139) and 31.1%, (38/122) respectively (P=0.348). Furthermore, there was also no significant difference in the morbidity of postoperative EJS complications [extracorporeal group vs. intracorporeal group: 5.0% (7/139) vs. 82.% (10/122), P=0.302]. The severity of postoperative complications between the two groups was not statistically significant (P=0.289). In the intracorporeal group, the Orvil(TM) subgroup had more estimated blood loss [100.0 (100.0) ml vs.50.0 (50.0) ml, Z=-2.992, P=0.003] and larger incision [6.0 (1.0) cm vs. 5.0 (1.0) cm, Z=-3.428, P=0.001] than the Overlap subgroup, seemed to have higher morbidity of intraoperative complication [7.0% (3/43) vs. 2.5% (2/79),P=0.480] and postoperative complications [37.2% (16/43) vs. 27.8% (22/79), P=0.286], and more severe classification of complication (P=0.289). Conclusions: The intracorporeal EJS after LTG has similar safety to extracorporeal EJS. As for intracorporeal EJS, the Overlap method is safer and has more potential advantages than Orvil(TM) method, and is worthy of further exploration and optimization.目的： 分析比较腹腔镜全胃切除术食管空肠经辅助切口圆形吻合与腔内吻合的安全性和有效性。 方法： 采用回顾性队列研究方法，收集2018年10月至2021年6月期间，在南方医科大学南方医院普通外科行腹腔镜全胃切除、D(2)淋巴结清扫、并完成食管空肠Roux-en-Y吻合术、具备术后6个月完整随访资料的261例胃癌患者的临床资料。根据患者食管空肠吻合方式不同进行分组，采用经辅助切口圆形吻合139例（辅助切口圆吻组），腔内吻合122例（腔内吻合组），腔内吻合组中OrVil(TM)吻合43例（OrVil(TM)吻合组），Overlap吻合79例（Overlap吻合组）。与辅助切口圆吻组的基线资料比较，腔内吻合组患者的体质指数偏大，肿瘤直径偏小，肿瘤T分期和M分期偏早，差异均有统计学意义（均P<0.05）；与Overlap吻合组基线资料比较，OrVil(TM)吻合组术前合并胃癌所致梗阻比例以及侵犯食管的比例均较高，T分期较晚，差异均有统计学意义（均P<0.05）；两组其他基线资料的比较，差异均无统计学意义（均P>0.05）。主要观察指标为比较辅助切口圆吻组与腔内吻合组以及OrVil(TM)吻合与Overlap吻合两个亚组的术后6个月内并发症发生情况；次要观察指标为上述各组手术情况、术中并发症发生情况以及术后恢复情况的比较。符合正态分布的连续变量采用x±s表示，两组间比较采用t检验；非正态分布的连续变量用M（IQR）表示，两组间比较采用Mann-Whiney U检验；分类变量用例（%）表示，组间比较采用χ(2)检验、连续校正χ(2)检验或Fisher精确检验。 结果： 辅助切口圆吻组与腔内吻合组手术情况比较，腔内吻合组手术切口更小[5.0（1.0） cm比8.0（1.0） cm，Z=-10.931，P=0.001]、联合脏器切除比例更低[0.8%（1/122）比7.9%（11/139），χ(2)=7.454，P=0.006]、R(0)切除率更高[94.3%（115/122）比84.9（118/139），χ(2)=5.957，P=0.015]，差异均有统计学意义（均P<0.05）；辅助切口圆吻组和腔内吻合组术中并发症发生率分别为2.9%（4/139）和4.1%（5/122），两组差异无统计学意义（χ(2)=0.040，P=0.842）。在术后恢复方面，两组的首次下地活动时间、首次排气时间和腹腔引流管拔除时间比较，差异均无统计学意义（均P>0.05），但是辅助切口圆吻组比腔内吻合组更早恢复全流食和半流食[分别（5.1±2.4） d比（5.9±3.6） d，t=-2.268，P=0.024；（7.3±3.7） d比（8.8±6.5） d，t=-2.227，P=0.027]、术后更快出院[（10.5±5.1） d比（12.2±7.7） d，t=-2.108，P=0.036]，两组比较，差异均有统计学意义（均P<0.05）。辅助切口圆吻组与腔内吻合组术后6个月并发症发生率分别为25.9%（36/139）和31.1%（38/122），食管空肠吻合口并发症发生率分别为5.0%（7/139）和8.2%（10/122），两组差异均无统计学意义（均P>0.05）；两组术后并发症严重程度的差异亦无统计学意义（P>0.05）。腔内吻合组中，与Overlap吻合组比较，OrVil(TM)吻合组术中出血量较多[100.0（100.0） ml比50.0（50.0） ml，Z=-2.992，P=0.003]，手术切口较长[6.0（1.0） cm比5.0（1.0）cm，Z=-3.428，P=0.001]，术后拔除腹腔引流管时间更久[（9.5±6.1） d比（7.2±3.1） d，t=2.367，P=0.022]，差异均有统计学意义（均P<0.05）；与OrVil(TM)吻合组比较，Overlap吻合组术中并发症发生率低[2.5%（2/79）比7.0%（3/43）]，术后6个月并发症发生率也低[27.8%（22/79）比37.2%（16/43）]，并发症严重程度较轻[Ⅲ~Ⅳ级：7.6%（6/79）比14.0%（6/43）]，但差异均无统计学意义（均P>0.05）。 结论： 经辅助切口食管空肠吻合与腔内食管空肠吻合在安全性方面相当。而腔内Overlap食管空肠吻合较OrVil(TM)吻合更显安全、更具开展潜力，值得进一步探索优化。.